Inservice informs staff of Medicare/Medicaid ABNs

Here is the text of a staff inservice fact sheet on advance beneficiary notices developed by Liz Kehrer, CHAM, manager of patient access at Centegra Health System in McHenry, IL:

- ABN instructions

Medicare/Medicaid program restrictions do not allow for coverage of diagnostic testing in the absence of signs and symptoms/illness. The tests must be medically necessary. Providers must notify the patient in writing that Medicare/Medicaid will likely refuse to pay for a specific test/ treatment. This notification, called an advance beneficiary notice (ABN), must be given before the test/treatment is given. The reason(s) the service may not be covered must be stated. The health care provider cannot issue a general notice stating that Medicare/Medicaid denial of payment is possible or that the provider is not sure if Medicare/Medicaid will cover the prescribed service or treatment.

The information on the ABN form should include the service(s) ordered, the date of the service, the diagnosis and the specific reason why Medicare may decline payment. After the ABN has been explained to the patient, the patient decides whether to receive or decline the service and sign the ABN. The patient will then be financially responsible for paying the service(s) fee if Medicare/Medicaid declines payment.

The provider cannot collect any money from the patient for the service if a completed ABN was not signed by the patient before the service(s).

Present an ABN only if you doubt payment. Do not routinely ask all Medicare/Medicaid patients to sign an ABN. Use the ABN only when you believe Medicare/ Medicaid will deny payment for an ordered tests for one or more of the reasons listed in the ABN. Complete the ABN before presenting it to the patient. You must fill in the information before you present the ABN to the patient for signing. You cannot have a patient sign a blank form and then fill in the information later. Fill in the patient’s name, date of birth, service date and the ordering physician’s name at the top of the ABN. Write the name of the ordered test/ treatment. Check-mark which category of service you believe the ordered service falls under. Fill in the diagnosis and check mark the applicable potential reason(s) for Medicare/Medicaid denial. Obtain and fill in the approximate cost.

You are now ready to ask the patient if he or she agrees or declines the service(s) and ask the patient/guardian to sign the form. If the patient agrees to have the service and signs the form, the patient accepts responsibility for payment in the event Medicare/Medicaid does not pay for the test(s) performed. If the patient declines or does not want the test(s) performed, since he/she is not willing to accept personal responsibility for payment in the event Medicare/Medicaid does not pay for the ordered test(s), the ABN is still signed to document the discussion with the patient and the patient’s decision.

If the patient refuses to sign the ABN but still wants the test to be performed, you should ask a fellow Associate to witness that the patient has been notified of the specific information provided in the ABN; namely, that Medicare/Medicaid is likely to deny payment for the specific test(s) ordered, the reason(s) for doubting payment, that the patient could be personally responsible for payment in that instance, and that the patient had the right to refuse the test(s) but chose to have the test performed. Tell the witness to sign and date the bottom of the ABN form.